Credentialing Challenges and Solutions in Medical Groups

Medical Group Credentialing May 9, 2019 Steven Meixler, MD Medical Director, Vice President Westmed Medical Group

Role Medical Director, VP and Credentials Committee Chair of a Large Medical Group of 478 Providers oGroup holds 3 year NCQA Accreditation Medical Director of the Rye Ambulatory Surgery Center of 121 Providers oASC holds 3 year AAAHC Accreditation

Credentialing Challenges for a Provider Applicant - Privileges & Health Plan Enrollment Obtain clinical privileges at an in-network hospital Enroll with insurances

Solution If there is a delay in the hospital credentialing process or if the provider cannot obtain a Medical Board meeting date prior to starting with the employer (Medical Group), health plans allow admitting arrangements for all specialties. Frequently used for Internal Medicine, Family Practice and Pediatric providers that work in outpatient settings as Hospitalist Teams are experienced in Hospital Medicine. Arrangement is allowed as long as it is with a provider with the same like specialty and both providers have agreed to the arrangements in writing with signature approval.

Credentialing Challenges for a Participating Provider Employer Perspective Unique position You are credentialing a provider that has already been interviewed, selected and accepted the position. Fact: The provider will be employed unless you uncover an egregious issue. The provider wants to help you credential as soon as possible. A single provider or small group is not joining your Medical Group without your approval.

Solution Delegation with payers is key You have to have delegation in order to obtain the start date you want for your provider.

General Credentialing Challenges During The Credentialing Process Going through multiple credentialing processes for both the employer (Medical Group) and a hospital can at times be confusing.

Solution Establishing relationships is imperative to distinguish yourself from other medical groups, hospitals or CVO s that are also performing primary source verification. Simply put, pick up the telephone and figure out how to establish a human connection with the person you need information from while also explaining the duplicative nature of the situation.

General Credentialing Challenges During The Credentialing Process It s Not You it s Them Providers are disenfranchised by the process and sometimes stop communicating with you.

Solution Hand Hold the provider through the process every step of the way

General Credentialing Challenges During The Credentialing Process Locum Tenens Do Not Disclose Everything

Solution Get Creative Query the largest Locum Tenens agencies Ask for assignment locations & dates Request the medical malpractice insurance coverage then verify to obtain comprehensive start/end dates

General Credentialing Challenges During The Credentialing Process Multiple medical licenses needed Multiple hospital privileges needed Multiple office locations crossing state lines

Solution Let the Provider Know Ahead of Time During or after the interview Create a take away list of credentialing expectations

General Credentialing Challenges During The Credentialing Process Provider is relocating to work at your Medical Group Issues with internet access Too busy to communicate with you Can t find important documents

Solution Take the time to meet with the provider either in person or virtually via web cam

General Credentialing Challenges During The Credentialing Process Obtaining an application in a timely manner giving you enough time to credential by the requested deadline

Solution Obtain summarized credentialing information with the employment contract Simple applications User-friendly

Solution Return the signed employment contract with: 1. CV 2. Release & Consent 3. Minimal demographic data a) (DOB and SS#) Immediately start the credentialing process

The Importance of Quality for a Medical Group Quality reports are required to maintain NCQA accreditation Compliance Includes but is not limited to: Tracking patient complaints & compliments monthly, querying health plans for any complaints they may have received. Credentials Quality Committees work collaboratively to monitor, measure, review and present data that also includes peer review ratings, peer comments, medical malpractice cases by category as well as adverse events, documentation, citizenship and ongoing CME compliance.

Payer Challenges Question: Practitioner with no admitting privileges but would fulfill a need in a particular geographic area, how do you address? Answer: Establish admitting arrangements between the provider and another provider with the same specialty that holds privileges at an in-network hospital.

Red Flags Establish red flag criteria and uniformly apply it.

Questions/Comments?

Thank you for your time and thank you for Thank you for your time and thank you for all that you do. all that you do. You You are the first line of defense for patients. are the first line of defense for patients. What you do every day is What you do every day is very important THANK YOU! THANK YOU! very important. .